Experts warn why we need to stop treating back pain with opioids

Opioids are one of the most prescribed pain relievers for people with back and neck pain. In Australia, about 40 percent of people with back and neck pain who present to their GP and 70 percent of people with back pain who visit a hospital emergency department are prescribed opioids such as oxycodone.

But our new study, published July in the Lancet medical journal, found opioids do not relieve “acute” back or neck pain (lasting up to 12 weeks) and can result in worse pain.

Prescribing opioids for low back and neck pain can also cause harm ranging from common side effects—such as nausea, constipation, and dizziness—to abuse, dependence, poisoning, and death.

Our results show that opioids should not be recommended for acute back or neck pain. A change in prescribing for back and neck pain is urgently needed in Australia and globally to reduce opioid-related harm.

Comparing opioids to a placebo

In our trial, we randomly assigned 347 people with acute back and neck pain to take an opioid (oxycodone plus naloxone) or a placebo (a tablet that looked the same but had no active ingredients).

Oxycodone is an opioid pain medicine that can be given orally. Naloxone, an opioid reversal drug, reduces the severity of constipation without interfering with the pain-relieving effects of oxycodone.

Participants took the opioid or placebo for up to six weeks.

People in both groups also received education and counseling from their doctor. This could be, for example, advice to return to their normal activities and avoid bed rest.

We evaluated their results over a period of one year.

What did we find?

After six weeks of treatment, taking opioids did not result in better pain relief compared to placebo.

There were no benefits for other outcomes, such as physical function, quality of life, recovery time or work absenteeism.

More people in the group treated with opioids had nausea, constipation and dizziness than in the placebo group.

The one-year results highlight the potential long-term harm of opioids even with short-term use. Compared to the placebo group, people in the opioid group had slightly worse pain, and they reported a higher risk of opioid use (problems with their thinking, mood or behavior, or the use of opioids differently from the way the medicines were prescribed).

More people in the opioid group reported pain at one year: 66 people compared to 50 in the placebo group.

What does this mean for opioid prescribing?

In recent years, international back pain guidelines have shifted the focus of treatment from drug to non-drug treatment due to evidence of limited treatment benefits and concern about medication-related harm. .

For acute back pain, the guidelines recommend patient education and counseling, and if necessary, anti-inflammatory pain medications such as ibuprofen. Opioids are only recommended when other treatments have not worked or are not approved.

Neck pain guidelines discourage the use of opioids.

Our latest research clearly shows that the benefits of opioids do not outweigh the possible harms in people with acute back and neck pain.

Instead of recommending the use of opioids for these conditions in selected circumstances, opioids should be discouraged without qualification.

Change is possible

Complex problems like opioid use require smart solutions, and another study we recently conducted provides compelling data that opioid prescribing can be successfully reduced.

The study involved four hospital emergency departments, 269 clinicians and 4,625 patients with low back pain. The intervention consists of:

  • clinical education on evidence-based management of low back pain
  • Patient education using posters and handouts to highlight the benefits and harms of opioids
  • provide heat packs and anti-inflammatory medications as alternative pain management treatments
  • quick referrals to outpatient clinics to avoid long waiting lists
  • audits and feedback to clinicians on information on opioid prescription rates.

This intervention reduced opioid prescribing from 63 percent to 51 percent of low back pain presentations. The reduction was sustained for 30 months.

The key to this successful approach is that we worked with clinicians to develop appropriate opioid-free pain management treatments that were feasible in their setting.

More work is needed to evaluate this and other interventions aimed at reducing opioid prescribing in other settings, including GP clinics.

A nuanced approach is often necessary to avoid causing unintended consequences in reducing opioid use.

If people with back pain or neck pain use opioids, especially in higher doses for an extended period of time, it is important that they seek advice from their doctor or pharmacist before stopping these medicines to avoid unwanted effects when the medicines are suddenly stopped.

Our research provides compelling evidence that opioids have a limited role in the management of acute low back and neck pain. The challenge is to get this new information to clinicians and the general public, and to implement this evidence in practice.

Christine Lin, Professor, University of Sydney; Andrew McLachlan, Head of School and Dean of Pharmacy, University of Sydney; Caitlin Jones, Postdoctoral Research Associate in Musculoskeletal Health, University of Sydney, and Christopher Maher, Professor, Sydney School of Public Health, University of Sydney

This article is republished by The Conversation under a Creative Commons license. Read the original article.

An earlier version of this article was published in June 2023.

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